Thoracoscopic enucleation of a large esophageal leiomyoma using a three thoracic ports technique
© Akaraviputh et al; licensee BioMed Central Ltd. 2006
Received: 26 June 2006
Accepted: 04 October 2006
Published: 04 October 2006
Video assisted thoracoscopic resection of an esophageal leiomyoma offers distinct advantages over an open approach. Many papers have described various techniques of thoracoscopic resection.
We describe a 32-year old man who presented with intermittent dysphagia. Imaging studies showed a large esophageal leiomyoma. He underwent thoracoscopic enucleation using a three thoracic-ports technique.
Thoracoscopic enucleation can be technically performed using a three thoracic-ports technique.
The list of publications reporting thoracosocpic enucleation technique for esophageal leiomyoma.
Everitt et al 
Right-sided approach: 7 trocars
Izumi Y et al 
Right-sided approach: 6 trocars
Schmid et al 
Right-sided approach: 4 trocars
Roviaro et al 
Rtght-sided approach: 3 trocars with small thoracotomy
Infante et al 
Left-sided approach: 4 trocars
Coral et al 
Right-sided approach: 4 trocars
Rahden et al 
Right/Left sided approach: 4 trocars
Right-sided approach: 3 trocars
Barium swallow at day 3 after surgery revealed no leakage and the patient was started on a liquid diet on day 4. The pathological report showed a leiomyoma with mitotic figure 0–1 per10 high power fields (HPF). Immunoperoxidase stainings were positive for smooth mucle actin, and negative for S-100, CD34 and C-kit. The patient was discharged on postoperative day 6. The patient is currently asymptomatic three months after surgery.
Esophageal leiomyoma is an uncommon benign tumor of smooth muscle origin. The most common anatomical location is in the lower third of the esophagus . Malignant degeneration is rare, but removal is often required on symptomatic grounds. The characteristics of the lesion are clearly seen using esophagoscopy and conventional imaging techniques (barium swallow, CT scan, EUS) without the need for preoperative endoscopic biopsy . Thoracoscopic enucleation is less invasive than open surgery, avoiding scaring and the discomfort of thoracotomy.
A thoracoscopic approach offers potential advantages compared with traditional thoracotomy, including minimal aesthetic disability, less pain, and better postoperative respiratory function. The limited operative trauma should allow a reduced postoperative hospital stay and more rapid resumption of normal activity .
The leiomyoma enucleation was easily performed and the esophageal muscular layer was carefully closed because of the reported development of a pseudodiverticulum after the procedure [6–8]. Intraoperative endoscopy with air insufflation confirmed an intact mucosal layer without any degree of esophageal stricture after suturing.
Some authors state that intraoperative endoscopy is not necessary to detect any perforation, because they infused blue dye proximally to the tumor after distal compression to create a bulge in the mucosa . However, intraoperative endoscopy can reveal an electrical injury to mucosa which cause delayed perforation.
The advantages of thoracoscopic removal of esophageal leiomyoma are confirmed in the limited series that have been published in recent years. Of particular significance is the relative simplicity of this kind of approach compared with traditional thoracotomy . Even with previous reports using four thoracic ports, the technique is applicable with three ports without any special instruments. This technique can be performed without morbidity and mortality, as in the recent study described.
Thoracoscopic enucleation is treatment of choice of esophageal leiomyoma. Even with previous reports using four thoracic ports, the technique is replicable with only three ports.
Written consent was obtained from the patient for publication of this case report.
We would like to thank Dr. Narong Lert-akayamanee and the Faculty of Medicine, Siriraj Hospital, for all their help in the preparation of this manuscript.
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